In what many called an act of political courage, Gov. Peter Shumlin of Vermont devoted last year's annual State of the State to what he termed a “crisis bubbling just beneath the surface that may be invisible to many.” A year later, Vermont has developed a reputation as the nation's most proactive state in the fight against drug addiction.
Some of Vermont’s policy changes started before Shumlin’s now-famous address; many started in other states; and their impact can’t be fully assessed in only a year. But, taken as a whole, they represent a comprehensive approach and a shift in the ways health and criminal justice systems treat drug addiction.
“Clearly, the problem is bigger than our ability to solve it right now,” said Deb Richter, a primary care physician at a residential treatment center in Vermont. “The amount of heroin on the streets and elsewhere in this country (and it’s the entire country) is mind-boggling.”
By the National Institute on Drug Abuse's measure, the number of heroin users nationwide doubled from 380,000 to 670,000 between 2005 and 2012, and fatal overdoses spiked about 50 percent to 2,780 in 2010. In Vermont, annual overdose deaths from opioids overall have nearly doubled since 2004, and emergency department visits for opioids have increased about 50 percent since 2009. In terms of overall use reported in official federal surveys, Vermont is in line with the rest of the country or lower than other hotspots of addiction.
But the best source of data to illustrate the scale of the problem is the number of people coming in for treatment, according to Bob Bick, the executive director of Howard Center, which provides substance abuse services. The number of people seeking treatment for opioid addiction has surged 770 percent since 2000. As of November, 2,517 people were getting treatment for opioid addiction -- up from 1,704 at the beginning of 2014, with a waiting list of 523 remaining.
“That’s telling you what you’re really confronted with,” Bick said.
What sets Vermont apart is the scale of its effort to reorganize its health system as well as expand access to care and shift its criminal justice system toward treatment.
Rapidly expanding the availability of doctors who can treat opioid addiction and creating a better-coordinated system for patients got its start before Shumlin’s address, but much of the implementation took place this past year. Spending increased 40 percent with the help of a federal matching program that covers 90 percent of costs through two years to encourage states to create team-based approaches to patients with chronic conditions such as drug addiction.
Gov. Peter Shumlin delivers his 2014 State of the State address. (AP/Andy Duback)
To better coordinate care, the state is now divided into five geographic regions, each of which has a medical "hub" that assesses the severity of the problem, tests for related issues such as hepatitis C, provides methadone (a drug used to treat withdrawal) when warranted, works toward stabilizing patients, and connects patients to residential treatment or outpatient services. The state refers to those next-step services as “spokes.”
At the same time, the state is trying to shift reliance away from residential services toward family doctors, counselors and therapists to reduce hub waiting lists and provide more inpatient days to the people who need it most. There's required reviewing to determine whether patients still need residential services after 15 days -- a tactic similarly used by at least 18 other states. If patients don't meet the standards, they continue treatment with a regular doctor. But Richter, the primary care doctor, argues two weeks isn't enough time to help addicts avoid relapses, pointing to research that links longer residential stays with better outcomes.
“What I’m finding is we’re getting a lot of bounce back,” she said. “Two weeks is not enough to change behavior.”
But the state argues it’s merely following the American Society of Addiction Medicine's guidelines and more closely aligning public benefits with what's offered by private insurers, who typically enforce stricter limits than Medicaid. In a December report to the legislature, health officials said since the state started its new policies, 75 percent of requests for additional days in residential treatment have been approved, relapses increased only slightly from 13 percent to 15 percent, the number of people receiving care rose 21 percent and the percent of patients reporting improved health after discharge grew as well.
“I think there was a lot of fear among residential providers that this was going to really limit care,” said Barbara Cimaglio, the deputy commissioner for Alcohol and Drug Abuse Programs at the Vermont Department of Health. “We haven’t seen that. In fact, it’s opened up this level of care to more people.”
But Richter insists there’s a different feeling among doctors, and she said it’s exacerbated by the shortage of primary care physicians to take over once patients are stabilized but still need ongoing care and possibly medication to curb opioid cravings, which doctors need federal certification to prescribe.
The problem isn’t the federal certification, which doctors can obtain with an eight-hour online training course, but having enough medical providers who are willing to take on patients with drug addiction, Cimaglio said. Bick, the executive director at the Howard Center hub, said he has about 180 patients who could be served in a primary care practice, which would open up space for the almost 300 people still waiting.
“We just don’t have enough physicians willing to do that right now,” he said.
The medical system changes are only one aspect of Vermont’s approach to drug addiction. The other reforms have focused on shifting the criminal justice system away from a punitive response to drug addiction. Some of the state’s ideas started elsewhere, but in several ways, Vermont has pushed them further, according to national analysts.
Take drug overdose immunity -- or “Good Samaritan” -- laws, for example. Twenty-two states have enacted some form of immunity law, which shields users and the people with them from arrest when calling 911 in the event of an overdose, according to the National Conference of State Legislatures. In most states, immunity only extends to possession and other low-level crimes, but Vermont’s law shields people from being charged with manufacturing or selling drugs when seeking medical assistance for an overdose.
And while many states are increasing the availability of the overdose-reversing drug naloxone, Vermont was the first state to allow pharmacies to sell it over the counter, according to Lindsay LaSalle, an attorney at the Drug Policy Alliance, which advocates for drug laws that focus on harm reduction instead of criminal penalties. Of the 800 overdose-reversal kits distributed since the law passed, more than 80 have been used. Health officials argue that's evidence that they're already saving lives, but the limited health statistics available indicate that there will be more heroin overdoses in 2014 than the year before.
Naloxone reverses the effects of an opioid overdose. (David Kidd)
Additionally, over the last legislative session, Vermont passed a statewide system of mandatory pre-trial assessments that evaluate the risk of releasing a prisoner -- something only a handful of states have done system-wide. That system also allows judges to use that assessment to require treatment for drug offenders before they’re even charged, establishing drug addiction as a condition to avoid prosecution. The belief is that such policies can help people better maintain employment and stable lives. Allowing judges to take those measures without issuing a charge hasn’t been tried statewide, according to another analyst at the Drug Policy Alliance, and neither has a new program that maintains treatment for people in prison and while they transition out of prison.
“Regardless of whether you call it a pilot or something else, it’s the only state in the country doing it,” LaSalle said.
Shumlin has acknowledged that much of Vermont's efforts are an “experiment." He’s faced little criticism from people who think the policies could be too lenient, partially because his party also controls the legislature, which has been nearly unanimous in its support for the governor's recent drug policymaking. Shumlin Spokesman Scott Coriell didn’t return multiple messages seeking comment.
Assessing the impact of the changes in the criminal justice system at this point is difficult. Vermont's opioid fatalities last year were on track to top 2013's record for heroin deaths, but Cimaglio maintains they would've been far higher without the policy changes over the past year and a half.
She expects overdoses and other drug abuse statistics to decrease as the state continues to pour resources and attention into the problem. The state will have to take over more of those costs after 2016, though, as the federal program that's helped boost funding lowers its matching rate. But despite facing a $100 million budget deficit, Shumlin said Thursday that his proposed budget will increase funding to combat heroin.
“Together, Vermonters are facing the ravages of heroin and opiate addiction in our families, friends and communities, and we must continue to fight,” he said.